From Clinic to Kindergarten: A Path Toward Equity in School Readiness

Poverty¹ and systemic racism² are critical causes of disparities in early child development and school readiness. Because these early disparities result in lifelong barriers to educational achievement, health, and economic security, there is consensus regarding the urgency of early preventive efforts. Pediatric primary care provides a unique opportunity for population-level engagement of the highest-risk families to support nurturing parent-child relationships critical to healthy child development.^3,4 Parent-child book sharing supports early relational health,⁵ social emotional development,^6,7 and early literacy,⁸ representing a modifiable target for intervention.

Over 30 years, Reach Out and Read (ROR) has achieved the highest level of evidence and implementation, to our knowledge, of any early childhood developmental promotion program, with 6100 medical practices reaching 4.5 million children annually.⁹ In numerous studies, authors have documented large impacts on reading aloud and child language development from the infant-toddler periods through school entry^10–12 at a fraction of the cost of intensive parenting interventions like home visiting.

In the current issue, Szumlas et al¹³ added significantly to the evidence base for ROR and health care–based population-level prevention through an innovative study design. First, they combined ROR with Dolly Parton’s Imagination Library (DPIL),¹⁴ greatly increasing families’ access to books. Second, they leveraged ROR infrastructure to integrate DPIL enrollment across 23 sites, reducing family barriers. Third, they tied participation to children’s performance on kindergarten readiness assessments, a national education strategy used in 37 states and Washington, DC.¹⁵

The study’s most important finding was a reduction in early literacy gaps at kindergarten entry in three successive cohorts, each participating for longer periods. Importantly, findings linked family participation in developmental promotion targeting the home learning environment to potential increases in school readiness as measured by a state’s kindergarten readiness assessment. Although the study was exploratory, findings are critically important given the programs’ low cost and high scalability, strongly supporting the need for both further research and strengthened implementation.

In addition, the study revealed the feasibility of population-wide early literacy promotion in primary care using ROR, with potential synergies when complemented with community-level promotion through DPIL. Findings therefore provide support for using the medical home as a platform for multilevel initiatives, an approach increasingly recognized as critical for significant population impacts (eg, New York City Council City’s First Readers^16,17 and Get Ready Guilford,¹⁸ large-scale initiatives including ROR).

In addition, findings provide strong support for the role of children’s books as a key component of developmental promotion, revealing that increasing books at home may reduce school readiness gaps. Although extensive research reveals that books promote verbal interactions,^19–21 this is the first study to our knowledge highlighting the potential for book quantity to enhance outcomes. This suggests that children’s books should be integrated within antipoverty efforts seeking to bolster family resources.

Finally, by linking this program to educational data, investigators achieved a methodologic breakthrough for demonstrating community-level effects. Their approach effectively reduced silos between health and education, providing a pathway for future studies seeking to show population-level impacts of health care–based programs, something rarely achieved in research.²²

In short, this study revealed a critical role for pediatric primary care in universal promotion of early child development. This is important because policies have frequently focused instead on primary care’s role in screening and referral. A comprehensive, blended strategy supporting families as their child’s first teacher through universal prevention in primary care (eg, ROR), complemented by additional supports for families with identified needs, is necessary to prevent and eliminate disparities. Meeting the needs of families, especially low-income families, requires effective referral and linkage to a cross-sector network of community-based services within a coordinated early childhood system^23,24 that includes health services, family support and parenting programs, and early learning.^25,26

Implementing universal developmental promotion in the medical home requires both ongoing payment for providers (Medicaid and other payers) and a funded infrastructure to implement a population-wide program across disparate clinical systems and communities. ROR, with a national center, 30 affiliates, 6100 clinic sites, and 33 000 trained pediatric clinicians, is by far the largest population-level network in existence. It is urgent that such infrastructure be sustained and expanded to provide a strong foundation for program quality and health care integration within kindergarten readiness initiatives nationwide.²⁷

Economic and racial inequities are a defining force in American society that must be actively dismantled. The coronavirus disease 2019 pandemic has exacerbated inequities in both health and education²⁸ and has highlighted the critical importance of supporting early parent-child relationships. We know that children need books at home and that parents who are supported will share books with their child and help them be ready for school. We know that ROR works and how to scale it. Implementing an affordable, scalable, proven strategy to support families that measurably increases kindergarten readiness while reducing inequities would be a true game changer for educational opportunity. If we do not act for equity in health and education now, then when?

Glossary

DPIL

Dolly Parton’s Imagination Library

ROR

Reach Out and Read